Be still, my beating heart... actually, don't.

A brief intermission at SMACHEAD, and something that happened a few days ago in the ED.

This was the third day of the run of hot days. Summer this year has come late, with Christmas day cricket being played under overcast skies and the grass still green by the side of the road, but it seems to be making up for lost time.

So, three days of temperatures around forty degrees - one hundred and four in the US. Children with sunburn, old ladies with headaches, my bicyclist who almost cycled himself to death, and two broken hearts.

The first was Mr Grande, a huge man, easily one fifty kilos. Broad-shouldered, big-bellied, loud voice. He worked in a machine shop, lifting and working with huge machines, temperatures in the low fifties .

That's over one hundred and twenty degrees, working. Thank Christ I don't have to work like that for a living.

He'd been forced into the ED by his wife, and when pressed confessed to the odd episode of chest pain in the last few days. Just a dull ache, centre of his chest, going down both arms. Came on when he got breathless, made him feel like he was going to vomit. Seemed to get worse when he did something, like lifting that big manifold the other day. Fair made his heart race.

By this time Mr Grande had the undivided attention of three nurses and two doctors, especially when his ECG came out almost unreadable - it was a pattern called left bundle branch block. LBBB of itself can mean a number of things - a problem with the big valve between the heart and the aorta, abnormal growth of part of the heart (maybe in response to some other problem), an abnormality of the heart muscle itself - or a recent heart attack.

I got on the phone to the cardiologist. Florey doesn't have a 24 hour cardiologist -most of them work at the Royal. We have this complicated protocol where if a certain kind of heart attack patient comes in (and we didn't know this was one, but it was starting to look pretty much like it) we contact the on-call cardiologist and get them sent up to the Royal for 'stenting' - insertion of a thin tube into the blocked artery, solving the problem.

In the interim I left Mr Grande in the care of our medical registrar, Dr Anya, who used to be one of our top emergency registrars before she worked out how much better hours almost any other job had.

"You'll like Dr Anya. And she's very very good." I said to the nervous man. "In fact" and here I leant forward and lowered my voice, "you're in luck, because she's as clever as she is beautiful." He grinned, and I turned to walk out the door, and then paused. "Unfortunately for you, so am I - no, just joking, just joking. Nurse, maybe turn up the anginine a little more, Mr Grande looks distressed..."

I had not actually done this before (called the cardiologist for a transfer) and I was surprisingly nervous. Part of my brain was watching cubicle three, where Mr Grande stared bemusedly at the nurses flurrying around him, setting up infusions of mysterious liquids into each arm and popping tablets into his mouth - part of my brain was trying to stop the other parts panicking, and part was remembering my previous, not entirely happy, dealings with cardiologists.

There is a hierarchy in medicine, in a way the entire set-up resembles the renaissance Papacy (with consultants as cardinals and interns as penniless parish priests), and somewhere at the very very top are the interventional cardiologists. The men (overwhelmingly) who, when your heart starts to die because a blood vessel is blocked by fat or scarred by inflammation, will insert a thin wire in through the big vessel in your groin and save your life.

To a man* they are terrifying. An interventional cardiologist is good, and he knows it, and often, in medical school, he makes sure you know it too. From the cardiology viewpoint, a stethoscope is a telephone line to God... and when the cardiologist calls, God better pick up. At Mordor, where I did my medical training, Professor Maul was wont to pick the most nervous student out of the group and reduce them to tears of humiliation... without thinking or effort, the way someone else unlocks their car or peels an orange.

So I rang, to get the $300 000 a year man out of bed, just on midnight.

"Dr Mishka speaking" said Dr Mishka, sounding just like a normal man who had been fast asleep in his bed.

"Sorry to bother you, Dr Misha" I said. "My name is John Bronze and I'm calling from Florey with a 48 year old man with a history of chest pain and first presentation LBBB."

"It's Mishka" said the great man. "How stable is he?"

"Better stay away from the surname" I thought. "No haemodynamic compromise, Dr Mischa" Aaargh!!

"Mishka" said Dr Mishka gently. "And you've given aspirin, anginine, heparin...?"

Calm down. "It's running now, Dr Mothra". Jesus!!! I tried to grab hold of my tongue and pull it out of my mouth.

There was a faint sigh, but the gentle voice continued. "Well, that's okay then. Now, you may have rung the wrong number, because I'm not actually on call tonight - it's Professor Maul's night. But you're doing all the right things - write him up for some verapamil and give Maul a ring. Tell him you've discussed it with me. That's Hanif Mishka."

Anyway, it was funny at the time.

The second broken heart of the night was less so. I will post the tale of Mr Calvary later today... before lunch if my Cambodian prioson release doesn't make it in here.

Thanks for listening,
John

*With one exception, Dr Beatrice Corde, the single most universally admired doctor I have ever met. And the most terrifying. Ailing heart muscle does not die when Dr Corde treats it... it doesn't dare. One man told me his cholesterol count had dropped by ten under Dr Corde "probably out of terror", and another told me he had decided to give up smoking when she marched into his cubicle, grabbed his "secret stash" of cigarettes and hurled them out the fifth floor window.

John